Voluntary Medical Authority

As set out in the Department of Education, Training and Employment Pregnancy in the Workplace procedure and the Information Privacy Act 2009, your Rehabilitation and Return to Work Coordinator (or other authorised personnel including Principal and/or Manager) needs your consent to contact your treating medical practitioners and health care providers, as well as QSuper where relevant, in order to obtain and discuss information about your pregnancy for the purposes of ensuring your duties and workplace environment are appropriate throughout your pregnancy. The information may include sensitive or confidential health information.

The information will only be used for the purpose of ensuring your workplace safety during your pregnancy. Workplace safety focuses on ensuring your continuation of work and emphasises interventions, including modified hours, duties or relocation, aimed at maintaining you within the workplace.

The information will be maintained in confidence and stored securely. With your consent, the Rehabilitation and Return to Work Coordinator (or other authorised personnel including Principal and/or Manager) may disclose information to your treating medical practitioners and external rehabilitation providers involved in your workplace safety/rehabilitation.

However, the information may be disclosed by the Rehabilitation and Return to Work Coordinator without your consent where authorised or required by law. This may include disclosure to QSuper or doctors appointed by the Department for the purposes of advising the Department in relation to suitable alternate duties on medical grounds.

Additionally, information relevant to the impact that your pregnancy has upon your work may be discussed confidentially with your workplace supervisors, Regional, Institute or Central Office Organisational Health or Human Resources employees without your consent.

Authority

Please tick the boxes below as appropriate to indicate whether you consent to the listed activity in relation to information (which may include sensitive or confidential health information) relevant to your current illness/injury (“your information”) for the purpose of your workplace rehabilitation.

Activity / Yes / No / N/A
Do you consent to QSuper (where relevant) disclosing your information to the Department’s appointed Rehabilitation and Return to Work Coordinator or equivalent appointed officer? / ¨ / ¨ / ¨
Do you consent to the medical and health care providers listed in the attached Schedule disclosing your information to the Department’s appointed Rehabilitation and Return to Work Coordinator? / ¨ / ¨ / ¨
Do you consent to the Rehabilitation and Return to Work Coordinator disclosing your information to treating medical practitioners and external rehabilitation providers involved in your workplace health and safety? / ¨ / ¨ / ¨

(A photocopy of this consent form may also be accepted with the same authority as the original)

Signatures:

Employee: ______Witness: ______

Name (Please print):______Name (Please print): ______

Date: ___/___/___ Date: ___/___/___

Schedule: Medical Authority

(Use in conjunction with Voluntary Medical Authority. See Voluntary Medical Authority for privacy information)

Authority

I authorise the medical practitioners and health care providers below to disclose information (which may include sensitive or confidential health information) relevant to my current pregnancy to the appointed Rehabilitation and Return to Work Coordinator (or other authorised personnel including Principal and/or Manager) of the Department of Education, Training and Employment.

Note: The range of health care providers may include, but is not limited to medical specialists, allied health professionals and therapists. If insufficient room, attach another page and ensure that it is signed and witnessed as below.

Medical Practitioner / Address / Telephone

(A photocopy of this consent form may also be accepted with the same authority as the original)

Signatures:

Employee: ______Witness: ______

Name (Please print):______Name (Please print): ______

Date: ___/___/___ Date: ___/___/___

For further information about your privacy and the rehabilitation process, please contact the Department of Education, Training and Employment, Organisational Health Unit on 3235 9967 or http://education.qld.gov.au/health/ .

Uncontrolled copy. Refer to the Department of Education, Training and Employment Policy and Procedure Register at http://ppr.det.qld.gov.au to ensure you have the most current version of this document. Page 1 of 2